#34: De-mist-ifying Vaping – Clearing Up a Hazy Topic

September 15, 2021 | By Sam Masur

Summary

Is Vaping a cloudy concept for you? Fear not! Dr. Allison Heinly joins the show to share all you need to know about screening for vaping and e-cigarette use, nicotine replacement therapy, and e‐cigarette vaping‐associated lung injury. Take a listen – you’ll be mist-ified by all you learn!

Credits

Please consolidate if performing multiple jobs (e.g. Written and Produced by: Cyrus Askin MD; cover art and infographic by Kate Grant)

• Producer: Brian Ward, Jess Kelly MD
• Executive Producer: Maximilian Cruz MD
• Writer: Brian Ward, Jess Kelly MD
• Infographic: Jess Kelly MD
• Cover Art: Chris Chiu MD
• Hosts: Justin Berk MD, Chris Chiu MD
• Editor:Justin Berk MD; Clair Morgan of nodderly.com
• Guest: Allison Heinly MD

Vaping Pearls

1. Use scales for motivational interviewing to elicit patient-oriented reasons for quitting.
2. Flavors may be “banned” but they’re still out there. Menthol in particular is still available to vape, which disproportionately puts youth of color at risk.
3. Nicotine gum needs to be “parked” for a bit to work…  and make sure your patients get the flavored kind!

SPONSORS: VCU Health CE

We are excited to announce that the Cribsiders are now partnering with VCU Health Continuing Education to offer continuing education credits for physicians and other healthcare professionals. Check out cribsiders.vcuhealth.org and create your FREE account!

Vaping Notes 

About Dr. Heinly

Dr. Allison Heinly is a pediatrician and Assistant Professor of Pediatrics at Hasbro Children’s Hospital. She is an excellent teacher and has been selected twice for the Dean’s Excellence in Teaching Award for the Alpert Medical School of Brown University. Her career interests are in medical education and tobacco cessation/vaping, a topic which she teaches us all about in this episode! 

Screening for Vaping

1. Start the conversation early at the 12 year well child visit. Affirm the positive decision to not vape, and encourage teens to ask questions. 
2. Use terms teens understand (“Do you vape?”)
3. Make teens feel comfortable by starting with questions such as,  “Do you see this at your school?” or  “Are your friends Juuling?”
4. Emphasize confidentiality at the start of the visit! 

 Types of Vaping Devices

1.     Closed pod system (like Juul)

​​

Source: Juul.com

2.     Open & refillable

Source: CDC.gov

3.     Disposable e-cigarettes

Source: CDC.gov

What is in Juul? 

We don’t love using brand-names at the Cribsiders, but there’s no getting around this one: Juul is probably the most popular nicotine-containing product for teens today. It is a USB-style device that is easy to hide and vaporizes a “juice.” The “juice” includes water, flavoring, a humectant, and nicotine, particularly nicotine salt. The nicotine salt used is less irritating, but increases the addictive potential. Each Juul pod contains about 200 puffs, which is about the equivalent nicotine of a pack of cigarettes.

Flavors

There are many flavors of vaping, like mango and creme-brule. Flavors make vaping more attractive to children.  Flavors were banned by the FDA in 2020 in pod-based devices (like Juul), but are still allowed in disposable and reusable e-cigarettes. A notable exception to the flavor ban is menthol, which disproportionately affects communities of color (Delnevo, et al.; 2017)(Smiley et al., 2021). The FDA recently announced a plan to ban all menthol cigarettes and flavored cigars!

How to screen for addiction?

There are helpful checklists to screen for addiction out there, like the “Hooked on Nicotine” checklist and others. Some good questions to ask include:

• Do you feel the need to vape when you wake up?
• Is it hard to keep from vaping in places where you are not supposed to, like school?
• Do you feel nervous, restless, or anxious when you don’t vape?

Why screen?

There are first, second, and third-hand risks intrinsic to vaping, but the long-term health effects are not yet known. E-cigarette lithium batteries can explode and cause burns or death. Less than half a teaspoon of vaping liquid can be fatal to a toddler if ingested (Cameron et al., 2014).

Teens who vape have an increased risk for cough, wheezing, chronic bronchitis, and asthma exacerbations (National Academies of Sciences, Engineering and Medicine; 2018). This may be partly due to the inhalants in e-cigarettes and vaping devices, which include acrolein and formaldehyde (known cardiovascular toxins) and the heavy metals like tin, nickel, or lead from the coils used in many devices. We also don’t know how vaping affects the developing brain, especially with regards to mood and learning.

Teens who vape are at risk for nicotine addiction, and the younger the addiction starts, the harder it is to quit down the road. Vaping increases the odds of children moving on to combustible (conventional) cigarettes 3.5-fold, as well as the risk of using marijuana (Soneji et al., 2017, Park et al., 2020).

Tools for Quitting:

Start with motivational interviewing

Motivational interviewing has been shown to lead to future quit attempts (Catley et al., 2012)

• “What do you like about vaping? What do you dislike?”
• “Have you thought about cutting back?”
• “Are you ready to quit now? Are you ready to set a quit-date?”
  • Picking a quit date between 2-4 weeks seems to work the best, according to Dr. Heinly
• Use your scales! “On a scale of 1-10, how ready are you to quit today?” 
• Follow-up works! Keep bringing it up!

There are great cessation services at your fingertips!

• Each state has their own quitline –  some even provide FREE nicotine replacement therapy!
• This Is Quitting, or text DITCHVAPE to 88709
• Smoke Free Teens by the NIH (or text QUIT to iQUIT (47848))
• Tobacco21.org

Nicotine replacement therapy

Nicotine replacement therapy (NRT) is off-label for children; however, it is supported by the American Academy of Pediatrics (AAP) because it is safe and effective. It can take 2-4 months to quit effectively using NRT. NRT significantly increases quit rates in adults (Barua et al, 2018)

NRT is titrated based on how many cigarettes a patient smokes per day, however it is hard to tell how much nicotine is being used with vaping. 1 pod per day is equivalent to 1 pack per day (20 cigarettes). The Hooked on Nicotine Checklist can help differentiate between moderate and severe addictions. 

Use long acting nicotine (a patch) plus short acting nicotine (gum or lozenge)

For the PATCH:

1. Dosed at 21, 14, and 7 mg
   1. Start at 21 mg (severe addiction or  >1 pod per day) 
   2. Start at 14 mg (moderate addiction) 
2. Wear the initial patch for 6 weeks, then step down for 2 weeks
3. Rotate skin sites to avoid skin irritation
4. Wear 16-24 hours a day. If unable to sleep with the patch on, take it off at night

For the GUM or LOZENGE :

• Dosed at 4 mg or 2 mg 
  • Start at 4mg if vaping within 30 min of waking up or for severe addition
  • Start at 2mg for moderate addition 
  • Cut in half if the gum is too strong
• Gum chewing steps:
  • Chew like regular gum until you feel the tingle
  • Then park it on the gum for 30 seconds (have them hold between cheek and teeth)
  • Repeat at a different spot in your mouth
  • Make sure your patient asks for flavored gum.

Nicotine replacement for parents and caregivers

• The parents of your patients see pediatricians more than they see their own PCP! 
• Helping parents quit is a great opportunity to address their health and the health of their children. 
• Nicotine replacement (gum and patches) can be very expensive, so by providing parents and caregivers with a prescription, you can remove barriers to access. Refer to a quit line for free NRT (varies by state) if parents do not have health insurance.
• When you are recommending NRT, remember the contraindications:

• Severe arrhythmias
• New myocardial infarction within 2 weeks
• Severe or worsening angina
• Relative contraindication:Breastfeeding/pregnancy (Dr. Heinly likes to defer to the OB in these situations)

Other pharmacotherapy options for quitting nicotine 

Bupropion 

• Use in teens age 14+
• Great choice if a teen is also depressed
• Set a quit date AFTER the second week of therapy
• Can be used alone, combine with nicotine gum for carvings, or add in a nicotine patch (rarely needed)

Varenicline 

• Expert opinion: can also be used in teens, but Dr. Heinly rarely uses this

What about vaping to quit smoking?

Note that in adults, quitting smoking by vaping is not a proven technique, but is sometimes tried. However, vaping is NOT a recommended way to help teens quit traditional cigarettes and tobacco products.

A Word on a Virus Called COVID:

Young people who use e-cigarettes were about 5x more likely to be diagnosed with COVID, but the link is unclear (Gaiha et al., 2020). We don’t have clear data on vaping, but smoking combustible cigarettes particularly increases the risk of severe COVID illness (Lowe et al., 2021).

E-Cigarette/Vaping Associated Lung Injury: EVALI

How does EVALI present?

EVALI can mimic the flu, COVID, bacterial pneumonia, and many other things. Make sure you’re asking about vaping when taking a history!  There are a variety of presenting symptoms:

• Cough
• Pleuritic chest Pain
• GI symptoms 
• Fever and chills

Diagnosis

• A diagnosis of exclusion 
• Obtain chest x-ray (may see haziness or consolidation) and respiratory viral panel  
• May need CT if CXR is normal (will see bilateral ground glass opacities)

What else do we know?

Not much, to be honest… but we do know a bit:

• There have been about 2,700 reported cases in the US (Source: CDC) 
• The clinical course of EVALI can vary significantly between patients. Some patients have mild symptoms can be managed at home, but some patients may require ICU admission for respiratory failure and mechanical ventilation. 
• EVALI could be due to vitamin E acetate, an additive in THC-containing vaping products.
• Some physicians are using glucocorticoids to treat, but no clearly defined standard of care exists.
• The best prevention strategy is to reduce or eliminate vaping.

Take Home Points:

• Ask teens at every visit about vaping– the majority of teens want to quit, and you can help them (and their parents!)
• Think about EVALI when patients have respiratory, GI, or constitutional symptoms, and d ask about vaping use.

Goal

Listeners will understand how e-cigarette use affects young people and how to support quitting nicotine in all populations.

Learning objectives

After listening to this episode listeners will be able to…  

1. Recognize common e-cigarette products adolescents use and how to screen for them.
2. Practice motivational interviewing in the context of nicotine products.
3. Explain how to approach prescribing nicotine replacement therapy when indicated.
4. Describe the risks related to vaping, including EVALI.

Disclosures

Dr. Heinly reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Ward B, Kelly J, Heinly A, Masur S, Cruz M, Chiu C, Berk J. “De-mist-ifying Vaping”. The Cribsiders Pediatric Podcast. http://www.thecribsiders.com/ September 15, 2021